Pediatric oncologist referral practices for CAR T-cell therapy: A mixed methods study.
Authors: Anurekha Gollapudi Hall, Devan Duenas, Jenna M. Voutsinas, Vicky Wu, Adam J. Lamble, Benjamin Wilfond, Julie R. Park, Anurag Agrawal, Jonathan M. Marron
Journal: Journal of Clinical Oncology (2023)

10026 Background: Chimeric antigen receptor (CAR) T-cells are a promising therapy for children with relapsed/refractory B-acute lymphoblastic leukemia. However, few centers provide CAR T therapy, which may lead to disparate access, particularly for those from disadvantaged populations. Referral by pediatric oncologists is an essential step in this process—and one susceptible to bias—but prior literature evaluating referral practices for CAR T therapies is limited. Methods: We conducted a mixed methods study to better understand oncologists’ perspectives on barriers and facilitators to referral for CAR T therapies and possible biases in referral practice. Oncologists who previously referred patients for CAR T at five CPCI pediatric hospitals were emailed a survey. Descriptive statistics illustrated oncologist characteristics and factors influencing the referral process. We developed multivariable models to examine the association between oncologist characteristics, familiarity with CAR T, and referral practices. We conducted semi-structured interviews with a subset of participants and used thematic analysis to code transcripts. Results: 68 oncologists participated in the survey; 79% practiced at institutions with &gt; 50 new pediatric oncology diagnoses per year. Factors identified as most significantly influential in the decision to refer included goals of care (75%), family interest in CAR T (35%), support from enrolling site (25%), insurance (22%), and family resources (20%). 77% of oncologists expressed being ‘very familiar’ with CAR T and ‘very comfortable’ providing information about CAR T to patients and families. In multivariate analysis, Hispanic oncologists and those at institutions with fewer than 50 new diagnoses per year were less likely to express familiarity with CAR T (OR 0.02 (CI: 0.0001-0.91), p = 0.04 and OR 0.04 (CI: 0.003-0.30), p = 0.005). 38% considered non-clinical patient and family-level factors (compliance, social support, resources, insurance, language, education, and race or ethnicity) to be significantly influential in referral decisions. Oncologists who were Hispanic and those practicing for at least 20 years were more likely to consider these factors significantly influential (OR 14.52 (CI: 1.49-358.66), p = 0.04 and OR 6.76 (CI: 1.18-50.5), p = 0.04) in multivariate analysis. Nine oncologists completed in depth interviews; important factors in the referral process included ease of insurance approval and established partnership with CAR T center. Conclusions: Many oncologists consider factors in addition to medical criteria when deciding to refer patients for CAR T, raising concern for bias in the referral process. Familiarity with available CAR T therapies may also affect eligible patient referral. Future work should focus on identifying ways to improve familiarity with CAR T in order to optimize patient access, while ensuring equitable referral practices.